Transcript Medicaid Administrative Claiming “MAC”

Medicaid Administrative Claiming
“MAC”
2012-2013
Annual Staff Training
Training Introduction

Thank you for participating in this
important training. As teachers and
professionals who work daily with students,
your jobs involve much more than
instruction. Your efforts to link students
and their families to Medicaid-covered
health services that can impact a child’s
ability to learn provides structure and
support in developing successful learners.
Training Introduction
Your participation in Medicaid
Administrative Claiming (MAC) is a way in
which you can help your District to receive
reimbursement for Medicaid outreach and
associated health related activities you
provide. This reimbursement helps schools
to continue to provide vital health and
social services.
Thank you again for your participation in
this training and your work with Oregon
students and their families!
Money - Statewide

Feds award Oregon $22.5 million for
children's health insurance enrollment
 Since October 2010, Oregon has enrolled more than 53,000 kids
under age 19 in state health insurance.
 That enrollment success, plus outreach and streamlining by
the state Healthy Kids program, resulted in the bonus.
 This is Oregon's third year of receiving a bonus under the federal
law, including $15.1 million last year.
http://www.oregonlive.com/health/index.ssf/2011/12/feds_award_oregon_225_million.html
Money – Your District (Fall 2011)
District
Pool
Surveyed
% Claim
Total Claim
District Final Net Net Per Surveyed
Astoria
122
10
7.88%
125,209.89
59,391.41
5,939.14
Banks
88
14
0.98%
18,060.26
8,223.04
587.36
Beaverton
3015
190
0.75%
556,828.21
252,057.20
1,326.62
Clatskanie
62
14
9.21%
75,562.41
35,898.61
2,564.19
Forest Grove
499
40
0.97%
95,799.89
43,461.58
1,086.54
Hillsboro
1564
119
0.63%
122,754.51
51,177.95
430.07
Jewell
27
15
2.73%
6,661.44
2,981.39
198.76
Knappa
44
15
1.09%
5,518.90
2,429.32
161.95
NWRESD
268
19
0.40%
10,954.66
3,940.40
207.39
Rainier
85
15
2.99%
40,297.64
18,891.38
1,259.43
Sauvie Island
12
9
3.16%
3,737.80
1,732.18
192.46
Scappoose
163
14
3.04%
95,338.55
44,880.27
3,205.73
Seaside
142
12
1.61%
26,917.52
12,202.93
1,016.91
Sherwood
385
22
1.51%
91,600.24
42,005.90
1,909.36
Sherwood Charter 14
10
8.51%
7,690.54
3,616.14
361.61
St Helens
196
20
0.64%
24,428.06
10,746.73
537.34
Tigard-Tualatin
414
60
3.42%
291,946.98
137,848.46
2,297.47
Tillamook
182
16
1.53%
42,894.49
19,662.13
1,228.88
Vernonia
41
15
1.96%
13,213.42
6,130.33
408.69
Warrenton
82
15
9.32%
119,404.50
56,805.31
3,787.02
District Claimable Time Sample
What is Medicaid Administrative
Claiming (MAC)



MAC is a survey method of identifying and
accounting for the time spent by public school
staff on medically related activities, that
otherwise would be the financial responsibility
of the State.
The MAC process permits the costs of
allowable administrative activities being
performed in the school setting, to be
reimbursed under Medicaid.
The MAC program strengthens local
relationships between service providers and
public agencies.
Important Facts
 You
do not need to know who is
Medicaid/OHP eligible
 You do not need to know all about
Medicaid/OHP
 It is the activity you are doing that is
being measured, not the outcome of
the activity
 The time study determines your time
spent on eligible and non-eligible
activities
How is MAC time reported?

MAC claiming is reported by district staff
completing a web-based survey. The survey
documents services provided by school
personnel on a normal school day. There are
three survey periods per school year. Each
survey period has five survey days within the
period. Survey periods and dates are randomly
selected by DHS.
○ September – December
○ January – March
○ April – June
MAC Activity Codes

MAC Activity Codes
 A – School Related and Educational Activities
 B1 – Medicaid Outreach – Healthy Kids/Healthy
KidsConnect
 C1 – OHP Referral, Coordination, Monitoring and
Training
 C1 = Child Specific
 D1 – OHP Transportation/Translation
 E1 – Medical Program Planning, Policy Development,
and Interagency Coordination
 E1 = Everyone Benefits
 F – Direct Medical Services
School Related and Educational Activities

Code A
 This code should be used for
any school-related activities that
are not health related.
○ Including but not limited to
classroom instruction, grading
papers, supervision of staff,
recess duty, student discipline,
and developing curriculum.
 Note: Participating in an IEP
meeting must also be reported
as code A. (This includes the
development, coordination and
monitoring of a student’s IEP or
other education plan.)
Code B – Medicaid Outreach




B1.1 - Informing children and their families on how to effectively
access, use, and maintain participation in Medicaid/OHP.
(Includes describing the range of services, and distributing OHP
literature)
B1.2 - Assisting the student/family to access, apply for, and/or
complete the Medicaid/OHP application. (Includes transportation
and translation related to OHP application, and gathering
appropriate information)
B1.3 - Checking a student and/or family's OHP status.
B1.4 - Contacting pregnant and parenting teenagers about the
availability of Medicaid/OHP for prenatal and well baby care
programs.
Medicaid Outreach & Oregon Healthy Kids


Medicaid outreach activities are those performed to
inform eligible or potentially eligible individuals about
Medicaid and how to access the Medicaid program.
Oregon Health Plan/Healthy Kids Programs
 A State sponsored Medicaid program providing all
of Oregon’s uninsured children under the age of 19
access to no cost or affordable, comprehensive,
health insurance coverage.
What does it cover?

Healthy Kids covers all of the health care kids need
including:




Medical, dental and vision care
Regular checkups and preventive care
Prescription medicines and medical equipment
Mental health and chemical dependency services
Coverage lasts for a least one full year.
Who is eligible?
Three key qualifiers for no-cost or low-cost coverage
1.) Age
○ Must be under the age of 19 (19th birthday)
2.) Residency
○ Must live in Oregon and be a legal resident
3.) Income
○ Must have been without health insurance for two
months (exceptions: parent’s job loss or a child’s
serious medical need).
○ For free or low-cost coverage, household income
cannot be more than 300% of federal poverty level
($67,200.00 for a family of four).
Medicaid/OHP Services

Health Services
 Well-child exams
 Immunizations (May not be during exclusion or for education
enrollment requirements)
 Routine physicals
 Maternity and newborn care

Medical Services











Preventive services such as well-child check ups
Laboratory or x-rays
Treatment for most major diseases
Hospital stay
Substance abuse
Vision care, routine screenings, and glasses
Hearing services, hearing aids, & batteries
Home health care
Specialists care & referrals
Physical, occupational, and speech therapy
Medical equipment and supplies
Medicaid/OHP Services

Dental Services
 Preventive services (cleaning, fluoride treatments, sealants for







children)
Routine services (fillings, x-rays)
Dental check ups
Tooth removal
Dentures
24-hour emergency care
Specialist care and referrals
Mental Health Services





Evaluations
Therapy
Consultations
Medication management
Programs for daily and community living
B1 – Medicaid Outreach

B1.1
 Informing children and their families on how to
effectively access, use, and maintain participation in
Medicaid/OHP.
○ Includes describing the range of services, and
distributing OHP literature.
 Through interpreter, gave a family the details about qualifying
for OHP, application process and whom to contact.
 Worked with school counselor to answer a families questions
about OHP and how to apply. What benefits are covered,
eligibility requirements, etc.
 Informed the Grandmother of a student who needs extensive
surgery on his arm about OHP. The family is uninsured.
B1 – Medicaid Outreach

B1.2
 Assisting the student/family to access, apply for,
and/or complete the Medicaid/OHP application.
○ Includes coordinating transportation and providing
and coordinating translation related to OHP
application, and gathering appropriate information.
 Referred a family and helped contact and get an
application for Medicaid/OHP through our Family
Support Center.
 Phone call with a parent regarding documentation
requirements for the OHP application. Explained time
frame and importance of providing all documentation.
 Assisted a family with resources necessary for them to
apply for OHP.
B1 – Medicaid Outreach

B1.3
 Checking a student and/or family's OHP status.
 May be done by reviewing the families medical
card, contacting the local DHS agency, working with
in-district staff who have access to Medicaid
eligibility.
 Contacted parent regarding dental issues. Informed
them how to check OHP eligibility.
 Checked on the OHP status of a student returning from
foster care to her immediate family. She was covered
while in foster care but will need to reapply.
 Follow up with school counselor and County Mental
Health crisis unit regarding a student who attempted
suicide the previous day. Verified the student is not
insured and discussed access to OHP.
B1 – Medicaid Outreach

B1.4
 Contacting pregnant and parenting teenagers
about the availability of Medicaid/OHP for
prenatal and well baby care programs.
 Spoke with student regarding Medicaid/OHP for
prenatal care.
 Reviewed availability of Medicaid/OHP prenatal and
well baby programs during Youth Pregnancy
Opportunity Placement Meeting.
C1 - Referral, Coordination, Monitoring & Training
C1.1 - Referring students for medical, mental health,
dental health and substance abuse evaluations and
services covered by Medicaid/OHP. (Includes gathering
information in advance or referrals)
 C1.2 - Coordinating the delivery of medical health, mental
health, dental health and substance abuse services
covered by Medicaid/OHP. (Includes Youth Services Team
and CARE team meetings)
 C1.3 - Monitoring the delivery of medical (Medicaid/OHP)
covered services. (Includes monitoring and evaluating the
medical services component of the IEP)
 C1.4 - Training: Coordinating, conducting or participating in
training events or seminars for outreach staff regarding the
benefits of medical/Medicaid related services.

C1 - Referral, Coordination, Monitoring & Training

C1.1 - Referral
 Referring students for medical, mental health, dental
health and substance abuse evaluation and services
covered by Medicaid/OHP.
 Includes gathering information in advance of referrals.
 Discussion with team regarding the health needs of a
student who just returned from an out of state school.
Parent reports regression, team discussed referral to County
Mental Health agency.
 Met with student and mother. Student has substance abuse
issues. Referral to County Health Department for UA.
 Referral of a student with Mental Health needs to County
Mental Health.
C1 - Referral, Coordination, Monitoring &
Training

Immunizations
 Claimable – C1.1 Referral
 Administrative activities related to referrals to assist families in
accessing immunizations from enrolled Medicaid providers are
claimable as C1.1 - Referral.
 Not Free of Charge (Billed to Medicaid)
 Provided outside the school setting

Free Care Principal
 Precludes Medicaid from paying for the costs of
Medicaid-covered services and activities which are
generally available to all students without charge.
C1 - Referral, Coordination, Monitoring &
Training

Immunizations Continued
 Non Claimable – C2
 Administrative activities related to assisting children
and families to access “FREE” immunizations
 Activities performed in association with a free immunization
clinic offered in school or other settings
 Administrative activities performed in association with the
immunization exclusion requirements
- Performing a primary review summary
- Mailing exclusion orders
- Completing a county immunization status report
C1 - Referral, Coordination, Monitoring & Training

C1.2
 Coordinating the delivery of medical health, mental health, dental
health and substance abuse services covered by Medicaid/OHP.
○ Includes Youth Services Team and CARE team meetings
 Discussion with School Counselor regarding student who is in
need of health and mental health services and how to best
assist the family in gaining access to services through OHP.
 Followed up on OHP resources available for a student
needing glasses.
 Coordinating the delivery of medical services for a student with
depression (possibly suicidal) with administration, student,
family and DHS.
C1 - Referral, Coordination, Monitoring & Training

C1.3 - The 2003 CMS Medicaid Administrative Claiming
guide indicates the following are covered under code C1:
 Providing follow-up contact to ensure that a child has received the
prescribed medical/dental/mental health services covered by
Medicaid.
 Monitoring and evaluating the Medicaid service components of the IEP
as appropriate.
 When necessary and appropriate claimable scenarios may include:
 A classroom teacher who works closely with a student receiving Medicaid-covered
services on an IEP is involved in a team conference or meets individually with a
therapist to evaluate the medical component(s) of an IEP (this excludes the actual
IEP meeting).
 A classroom teacher who works closely with a student makes follow-up contact
with a qualified Medicaid Health Services provider to ensure services previously
prescribed or referred for were received.
C1 - Referral, Coordination, Monitoring & Training

C1.3
 The following monitoring activities are NOT claimable:
○ Activities performed in the initial development of the
IEP and/or formal IEP meetings (i.e., annual, 3-yr)
○ Monitoring minor acute health conditions, such as
scratches, bruises, headaches, colds, application of
Band-aids or administration of non-prescriptive
medications
○ Monitoring required by Delegation from a Registered
Nurse, such as seizure, catheterization, g-tube feeding
& blood sugar monitoring.
○ Monitoring of a diagnosed health condition (regardless
of the severity or type of health condition)
C1 - Referral, Coordination, Monitoring & Training

C1.4
 Training: Coordinating, conducting or
participating in training events or seminars for
outreach staff regarding the benefits of
medical/Medicaid related services.
○ Participating in a MAC training.
 Excludes the amount of time spent learning how to fill
out the actual survey.
○ Attending a seminar on how to effectively provide
OHP outreach.
○ The portion of a training where the content
focuses on recognition of signs and symptoms of
specific medical conditions.
 Suicide
 Autism
 Drug and Alcohol Abuse
C1 - Referral, Coordination, Monitoring & Training

C1.4
○ The following State Mandated
trainings are not covered:




First Aid Training
CPR Training
EPI Training
Blood-borne Pathogens Training
C1 - Referral, Coordination, Monitoring & Training


Activities required to coordinate or make referrals for
Medicaid covered services may be claimable for each
person involved, not just the final person to coordinate
or refer.
Example:
 Principal/Counselor asks you to put together information on a student
for possible referral to service – C1.1
 Meeting with Principal/Counselor/Other Teachers – C1.1
 Actual Meeting with Family/Student – C1.1


Just because you may not meet with the family, does not mean you are
not involved in gathering information or history in advance of the referral
that will reflect accurately the needs of the student
Students on an IEP – periodic meetings to review
effectiveness of medical component(s) – Claimable as
C1.3
 Activities that occur in a “Formal” IEP meeting are reported A. Periodic
meetings to review the effectiveness of the medical services, which
are NOT IEP meetings, may be claimable. Proper supporting
documentation must indicate the meeting was not an IEP meeting.
C1 - Referral, Coordination, Monitoring & Training
C1.1 can often lead to B1.1

If you meet with a student or family for a
referral to Medicaid Covered Services ask at
the end of the meeting “Would you like
information on State Programs that can help
pay for your child to receive these services”
 You don’t have to ask if they have insurance.
 The referral is to be reported as C1.1 regardless
 If the answer is yes, providing information on
Oregon Healthy Kids is appropriate and the
activity may be reported as B1.1.
D1 – Transportation/Translation

D1.1
 Scheduling and arranging transportation to OHP covered
services.
○ Does NOT include the provision of the actual transportation
service or the direct costs of the transportation (bus fare, taxi
fare, personal transport, etc, but rather the administrative
activities (related paperwork, clerical activities, staff travel
time, etc.) involved in providing the transportation.

D1.2
 Scheduling, arranging or providing translation for OHP
covered services.
○ Arranging for or providing translation services (oral and
signing) that assist the individual to access and understand
necessary care or treatment covered by Medicaid.
○ Developing translation materials that assist individuals to
access and understand necessary care or treatment covered
by Medicaid.
E1 – Program Planning, Policy Development & Interagency
Coordination
E1.1 - Developing strategies and policies to
assess or increase the capacity of school
medical/dental/mental health programs.
(Includes workgroups)
 E1.2 - Working with other agencies and/or
providers to improve the coordination and
collaboration and delivery of medical,
mental health and substance abuse
services.
 E1.3 - Monitoring the medical/mental
health/dental health delivery system in
schools.

E1 – Program Planning, Policy Development & Interagency
Coordination

E1.1
 Developing strategies and policies to assess or
increase the capacity of school
medical/dental/mental health programs
(includes workgroups)
 Worked with nurses and volunteers regarding
increased access to dental services for students.
 Review with school team current Mental Health
support system effectiveness.
E1 – Program Planning, Policy
Development & Interagency Coordination

E1.2
 Working with other agencies and/or providers to
improve the coordination and collaboration and
delivery of medical, mental health and substance
abuse services.
 Attended a community meeting in which access to Mental
Health services for students was discussed.
Brainstormed ways to improve access/delivery of Mental
health services to OHP eligible students.
 Attended a community resource meeting at DHS office.
We identified gaps in existing support systems and
collaborated w/various agencies about district wide
needs.
 Meeting: Collaborating with other agencies/providers on
available OHP options/programs to better serve students
in school with Mental Health needs.
E1 – Program Planning, Policy
Development & Interagency Coordination

El.3
 Monitoring the medical/mental health/dental
health delivery system in schools.
○ Developing advisory or work groups of health
professionals to provide consultation, advice
and monitoring of the delivery of health care
services to school populations.
○ Evaluating the need and/or effectiveness of
medical services provided in the school
setting (such as a school based health
center).
Code F – Direct Services

Providing Direct Services vs. Administrative
Activities
 The Centers for Medicare & Medicaid Services
(CMS) rule states: Activities that are considered
integral to, or an extension of direct medical
services, are NOT CLAIMABLE as an
Administrative expense (e.g., patient follow-up,
patient assessment, patient counseling, patient
education, patient consultation, billing activities).
These activities must be reported under
Code F, Direct Medical Services.
Non Covered Services – CODE F
EXAMPLES
 Treatment or monitoring activities related to minor
acute health conditions such as, scratches, bruises,
headaches, colds, application of bandages or
distribution of non-prescriptive medications.
 Physical monitoring of health/medical services on a
child’s IEP.
 (NOTE: Follow-up to ensure the activities on an IEP
(prescribed) are covered under C1.3.)

Monitoring a child’s health condition regardless of the
severity or type of condition.
 School secretary monitoring a child in the health room for
adverse reaction to a bee sting
 Teacher monitoring a child after an insulin injection
 Educational assistant monitoring a child following a seizure
Providing Appropriate Supporting Documentation

Take notes on any activity related to the medical needs of
students on the day of the survey (Form Provided)
 Don’t worry about what code it is – Just the time and activity




After survey day use MAC Activities sheet to determine
appropriate code
When in doubt – Ask!
Complete online survey
Provide a copy of the Supporting Documentation to your
district coordinator or NWRESD
 Keep FERPA in mind – general description of activity
 Saves asking 3 months later what you did!
Providing Appropriate Supporting Documentation
Time Frame
7:30-8:00
8:15-8:30
2:00-3:30
Activity Code
Description of Activity
Phone calls and email correspondence re: setting up appt. for applying for
OHP for two separate families
Gather info to share with parent for a different 6th grade student (suicidal)
who is currently seeing outside counselor under OHP to facilitate care
coordination.
Prevention Matters County meeting. Discussing mental health and
substance abuse services and trends in Washington County.
Coding Reminders

Coding Accuracy Reminders for Staff
 Reporting of Time:
○ Report only PAID work time
○ Report time in 15 minute blocks
○ Report all activities performed during the paid work
day
 Using Correct Login (name on paycheck)
 Saving the Survey
 Reporting unpaid lunch
○ time frame should be left blank on survey
 Reporting Paid Absences
○ code A
Online Survey – LAST STEP!
Employee Resources
Links to additional resources





http://www.oregonhealthykids.gov/ - Healthy Kids of Oregon is a program
that expands on the success of the OHP Program. No family makes too
much money for Healthy Kids.
http://www.oregonhelps.org/ - OregonHelps is a free and easy program
prescreener. This site will estimate your potential eligibility for 33 programs
and assistance.
http://www.oregon.gov/DHS/how_do_i.shtml – The main page for the
Oregon Department of Human Services with links to finding Medicaid
Services, Alcohol and Drug treatment centers, county health departments
and other Medicaid covered/related services.
http://www.oregon.gov/DHS/healthplan/managed-care/plans.shtml - OHP
Medical and Dental Plans by County. This page provides information to help
OHP and Healthy Kids applicants choose an OHP medical and dental plan.
http://egov.oregon.gov/DHS/mentalhealth/cmh-programs.shtml –
Community Mental Health Programs by County